Sexually transmitted infections and their sequelae such as infertility and chronic pelvic pain cause significant physical and psychologic morbidity. The diagnosis of an sexually transmitted infection affects well-being, self-confidence and personal relationships.

Many of those infected are unaware that they have an sexually transmitted infection, as symptoms are often absent or non-specific. Sexually transmitted infections are frequently multiple, so the presence of, say, warts or gonorrhea should lead the practitioner to consider other infections, such as chlamydia. Many factors can lead to the individual to delay or avoid seeking treatment, including embarrassment, fears of stigma, concerns about confidentiality, lack of awareness of sexually transmitted infections and ignorance or denial of the risk of infection. Prompt diagnosis and treatment of sexually transmitted infections is, however, important for both personal and public health as it reduces that chance of the individual developing complications and transmitting the infection(s) to others. The presence of some sexually transmitted infections (gonorrhea, herpes, syphilis, chancroid) leads to disruption of the surface barriers of the body (skin, mucosa) and facilitates HIV transmission. Thus, detecting and treating sexually transmitted infections also reduces the incidence of HIV.

The transmission of sexually transmitted infections can be lowered by changes in sexual behavior (abstinence, mutual monogamy and safer sex practices) and infection control programs (screening, early diagnosis, treatment of those infected, contact tracing and immunisation).

The burden of sexually transmitted infections is notoriously difficult to estimate. It varies according to the population studied, i.e., sex, age, race, occupation, education, rural, urban or inner city area are all important factors. The rates seen at genitourinary medicine clinics are higher than those seen at general practice. Many infection episodes are asymptomatic so any reported rate is likely to underestimate the real situation. Some recent epidemiologic data are depicted in Table New cases of sexually transmitted infections seen at genitourinary medicine clinics (England 2001) and new sexually acquired HIV infections (UK 2001).

Table New cases of sexually transmitted infections seen at genitourinary medicine clinics (England 2001) and new sexually acquired HIV infections (UK 2001)

Cases (n) Rate per 100 000 individuals aged 15-44 peryear
Sexuallytransmitted

infection

Male Female Male Female
Uncomplicated gonorrhea 15 476 6642 153 65
Uncomplicated chlamydia 29 166 38 248 288 373
Herpes simplex (first attack) 6492 10 558 64 103
Genital warts (first attack) 32 636 29 568 323 288
Infectious HIV 598 98 6 0.95

HIV, human immunodeficiency disease

General Considerations

Managing sexually transmitted infections in primary care

In the UK, genitourinary medicine clinics have the best facilities for diagnosing and managing sexually transmitted infections. Attending a special-ist clinic, however, may not always be practical or acceptable. Basic management of common sexually transmitted infections and other genital infections lends itself to protocols and so readily falls within the scope of appropriately trained doctors and nurses working in general practice and family planning. The ability to manage sexually transmitted infections in primary care is rapidly increasing with recent advances in diagnosis and single-dose therapy. Nucleic acid amplification techniques (NAATs), polymerase chain reaction (PCR) and ligase chain reaction (LCR) are increasingly available. They are more sensitive than many antigen and culture tests and are less dependent on rapid transport to the laboratory than cultures. Effective single-dose antibiotic therapy is now available for some sexually transmitted infections (gonorrhea and chlamydia) and for other non-sexually transmitted genital infections (candidiasis and bacterial vaginosis (bacterial vaginosis)).

The diagnosis of an sexually transmitted infection can have a major impact on the personal life and health of a patient. While making a positive diagnosis is important, so is reliably excluding sexually transmitted infections. It is therefore vital that quality standards are applied to the whole process of managing sexually transmitted infections (Table Management of sexually transmitted infections). To ensure that their patients can access the full range of services, it is important that individual practices have links with local genitourinary medicine clinics and microbiology laboratories.

Table Management of sexually transmitted infections

History and examination
Sexual history
Gynecologic history
Genital, pelvic and abdominal examination
General physical examination including mouth and skin, if indicated
Investigations/diagnosis
Decide
which diagnostic test should be taken and when?
which site(s) to sample
Optimize quality of specimens
good sampling
appropriate transport media
correct storage and rapid transport of specimens to laboratory
Treatment
Ensure correct treatment is given, taking into account local antibiotic resistance patterns and possibility of pregnancy
Consider epidemiologic treatment
Partner notification (contact tracing)
Counseling (emotional and sexual difficulties)
Patient information (verbal and written)
Confidentiality of service
Limitations of tests — which diseases have been tested for
Sequelae of infection
Effect of disease and its treatment on pregnancy and contraception
Transmission to partners (safer sex, asymptomatic shedding of herpes and wart virus)
Advise abstinence until partner(s) fully treated
Health promotion (strategies to reduce the risk of re-infection)
Follow-up
Carry out test of cure if indicated
Enquire about patient compliance (medication and abstinence)
Ascertain if partner(s) treated
Administration
Practice confidentiality policy
Liaison with local laboratory and genitourinary medicine service
Regular review of practice and audit

When to refer to genitourinary medicine services

Patients should be referred to a genitourinary medicine clinic when a special-ist service or an expert opinion is required. On-site microscopy at genitourinary medicine clinics enables presumptive diagnoses of gonorrhea and syphilis and definitive diagnoses of candidiasis, trichomonas and bacterial vaginosis to be made at the first visit. These clinics have facilities to inoculate culture media for gonorrhea, herpes and trichomonas directly, optimizing sensitivity. Therefore referral to a genitourinary medicine clinic is recommended for patients with genital ulceration, suspected gonorrhea and recurrent vaginal discharge. Patients with conditions requiring special-ist tests or treatment such as tropical diseases and syphilis should also be referred. Patients with warts should be offered referral to a genitourinary medicine clinic for treatment, especially if they are pregnant or do not wish to use podophylotoxin at home.

Referral to or liaison with the health advisor at the genitourinary medicine clinic should be considered for partner notification (contact tracing). Health advisors also provide counseling and health education. Finally, patients may prefer the relative anonymity and confidentiality of a genitourinary medicine clinic if they feel uncomfortable consulting their usual practitioner about an sexually transmitted infection or sexual difficulty.

Sexual history

Patients are unlikely to object to questions about their sexual relationships and previous sexually transmitted infections if they appreciate their relevance, especially if they perceive themselves to be at risk of infection. Seeking permission to ask personal questions, reassuring about confidentiality and only seeking information that will affect management, increases the acceptability of taking a sexual history (Table Establishing the sexual history of a patient).

Table Establishing the sexual history of a patient

Question Relevance
Number of partners
Regular partner(s) Establishes the risk of sexually transmitted infections and facilitates
Non-regular partner(s) in the last 3 months partner notification (if an sexually transmitted infection is detected)
For each partner
Partner’s gender and the nature of the sexual contact (i.e., receptive or insertive; vaginal, oral or anal intercourse) Establishes the risk and nature of a potential sexually transmitted infection and indicates which site to test
Length of relationship/date of last sexual contact Together with incubation periods, provides a guide when to perform tests
Condom use Establishes the risk of sexually transmitted infections and provides an education and counseling opportunity
Partner’s symptoms or diagnosis Risk of sexually transmitted infection, choice of test*
Overseas contact Consider tropical diseases and resistance to gonorrhea therapy

*For example, if partner has symptoms suggesting gonorrhea, practitioner should consider testing multiple sites, repeating negative tests or offering epidemiologic treatment. sexually transmitted infection, sexually transmitted infection

The use of gender-neutral terms such as ‘partner’ is helpful, as the women may be lesbian or bisexual. Some infections such as trichomonas can be spread between women, especially if sex toys are used, and some lesbians may be at risk of sexually transmitted infections from heterosexual contact in the past. Lesbians do not require contraception and so are less likely to attend family planning and well-women sessions. They should be offered sexually transmitted infection testing and cervical cytology examination as appropriate. It is recognized that the comfort level and skills to talk about sex may vary between practitioners and their relationships with patients.

Women who report sexual assault should be offered referral for both forensic (if they have not already reported the incident to the police) and clinical examination. If the woman chooses to have a forensic examination, it should be performed before the clinical examination. Assessment centers, known as ‘rape suites’, exist in some areas and are usually located in hospitals or police stations. They specialize in the forensic assessment of both male and female victims of sexual assault. According to the woman’s history, knowledge of the assailant and nature of the assault, clinicians should offer emergency contraception, hepatitis B vaccination and testing or prophylactic treatment for sexually transmitted infections and HIV. Counseling and referral to support organizations should also be offered.

Who to test for sexually transmitted infections

Sexually Transmitted Infection: Making A Diagnosis

Treatment Of Sexually Transmitted Infections

Bacterial Cervicitis and Pelvic Inflammatory Disease

Vaginal Infections

Genital Ulcers

Viral Infections And Infestations Of The Skin

Blood-Borne Sexually Transmissible Viruses

 

Share →